ExAblate Blood-Brain Barrier Disruption for Glioblastoma in Patients Undergoing Standard Chemotherapy

Inclusion Criteria:

1. Patient is eligible for adjuvant TMZ treatment based on the current standard of care.
2. Men or women.
3. Age between 19 and 80 years, inclusive.
4. Able and willing to give informed consent.
5. Grade IV glioma (GBM) confirmed through assessment of surgical specimens by a board-certified neuropathologist.
6. Combined radiation/TMZ treatment is completed based on the prescribed standard of care regimen.
7. Karnofsky rating 70-100 (See Appendix B).
8. Able to communicate during the ExAblate BBBD procedure.
9. Able to attend all study visits (i.e., life expectancy of at least 3 months).

Exclusion Criteria:

1. The sonication pathway to the tumor involves:

   i. More than 30% of the skull area traversed by the sonication pathway is covered by scars, scalp disorders (e.g., eczema), or atrophy of the scalp.

   ii. Clips or other metallic implanted objects in the skull or the brain, except shunts.
2. The subject presents with symptoms and signs of increased intracranial pressure (e.g., headache, nausea, vomiting, lethargy, and papilledema).
3. Patients with cerebellar or brainstem tumors.
4. Patient receiving bevacizumab (Avastin) therapy.
5. Patients receiving treatment with corticosteroid doses greater than dexamethasone 16mg daily (or equivalent).
6. Patients undergoing other concurrent therapies such as chemotherapy wafers, immunotoxins delivered by convection-enhanced delivery, regionally administered gene and viral therapies, immunotherapies, focal irradiation with brachytherapy, stereotactic radiosurgery, laser interstitial thermotherapy, and tumor treatment fields therapy. These regimens have been shown to cause contrast enhancement in the resection cavity boundary, which can be difficult to differentiate from true tumor recurrence \[35\] \[36\], \[37-39\].
7. Cardiac disease or unstable hemodynamics including:

   i. Documented myocardial infarction within six months of enrollment. ii. Unstable angina on medication. iii. Congestive heart failure. iv. Left ventricular ejection fraction \<50%. v. History of a hemodynamically unstable cardiac arrhythmia. vi. Cardiac pacemaker.
8. Severe hypertension (diastolic BP \> 100 on medication).
9. Anti-coagulant therapy, or medications known to increase risk of hemorrhage within washout period prior to treatment (i.e., antiplatelet or vitamin K inhibitor anticoagulants within 7 days, non-vitamin K inhibitor anticoagulants within 72 hours, or heparin-derived compounds within 48 hours of treatment).
10. History of a bleeding disorder, coagulopathy or with a history of spontaneous tumor hemorrhage.
11. Cerebral or systemic vasculopathy.
12. Evidence of new focal neurological deficits including, but not limited to, motor weakness or speech impairment within 7-14 days prior to the first BBBD procedure.
13. History of drug or alcohol use disorder.
14. Active seizure disorder or epilepsy (seizures despite medical treatment).
15. Known sensitivity to gadolinium-based contrast agents.
16. Known sensitivity to DEFINITY® ultrasound contrast agent or perflutren.
17. Contraindications to MRI such as non-MRI-compatible implanted devices.
18. Large subjects not fitting comfortably into the MRI scanner.
19. Difficulty lying supine and still for up to 4 hours in the MRI unit or claustrophobia.
20. Positive pregnancy test (women of childbearing potential).
21. Severely impaired renal function with estimated glomerular filtration rate \<30 mL/min/1.73m2 and/or on dialysis.
22. Right to left or bi-directional cardiac shunt.
23. Subjects with evidence of cranial or systemic infection.
24. Subjects with a family or personal history of QT prolongation or taking concomitant medications known to cause QTc prolongation, or QT prolongation observed on screening ECG (QTc \> 450 for men and \>470 for women).